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LEARNING OBJECTIVES

After completing this case study, the reader should be able to:

  • List the goals of anticoagulant therapy for periprocedural management of anticoagulation.

  • Appropriately assess a patient’s response to chronic warfarin therapy.

  • Evaluate thromboembolic risk for patients receiving warfarin therapy and determine the need for bridging therapy.

  • Develop a patient-specific pharmacotherapeutic plan for warfarin therapy and periprocedural management of anticoagulation.

  • Educate patients appropriately about administration of low-molecular-weight heparins (LMWH) and chronic warfarin therapy.

PATIENT PRESENTATION

Chief Complaint

“I am scheduled to have a colonoscopy and my physician said to talk to you about what to do with my warfarin.”

HPI

Elizabeth Heartly is a 53-year-old woman with a past medical history of severe mitral regurgitation status post (S/P) mitral valve replacement (MVR) 5 years ago who is receiving chronic anticoagulation. Today, she presents to the anticoagulation clinic for a follow-up appointment. She also reports that she is scheduled for a colonoscopy with possible polypectomy 2 weeks from today. She states her physician has been recommending the colonoscopy for routine screening since she turned 50. However, she has been reluctant to schedule it. She realized the need for the procedure after a friend was diagnosed with colon cancer. Although no biopsy is planned, her physician explained that she should be off warfarin in case a biopsy is needed. Ms Heartly reports taking one-half of a peach-colored warfarin tablet every Tuesday and Saturday, and one whole peach-colored tablet on the other days of the week. She states she uses a medication box and has not missed any of her warfarin doses during the last month. She denies any bleeding, excessive bruising, severe headaches, abdominal pain, numbness, tingling, or inability to move one side of her body. Her diet with respect to green, leafy vegetables has been consistent. She states that her arthritis has been really flaring up and therefore has been taking ibuprofen 800 mg TID for the last 2.5 weeks. She has one glass of red wine with dinner each evening. She confirms taking all other medications on her medication list and has not started any other new prescription, over-the-counter or alternative therapies.

PMH

Mitral regurgitation S/P MVR with St. Jude’s mechanical cardiac valve 5 years ago

Hypothyroidism

Osteoarthritis of the knee

FH

Father—colon polyps removed when he was in his 50s but is currently alive and well in his 80s.

Mother—hypertension and is 79 years of age.

Brother—healthy.

She has two children who are alive and well.

SH

(+) ETOH—one glass of red wine ...

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